Misophonia: An Interview Between and CAA

‍Can you explain what Misophonia is and how it differs from other auditory disorders (e.g., hyperacusis)?

‍Misophonia, unlike Hyperacusis, is not an auditory system based disorder. It is a disorder of abnormal emotion processing of sound. More specifically, misophonia is a disorder of decreased emotional tolerance to specific pattern-based, repetitive sounds that have a particular meaning to the individual. It tends to involve very strong negative emotional responses to particular sound stimuli. Auditory system is just the medium of which allows the offending sounds to get to the emotional processing centers within the brain.Whereas Hyperacusis, is a disorder of the central auditory nervous system and is defined as decreased sound tolerance to everyday normal sounds and is based on the intensity (dB) characteristics of those sounds. In a severe capacity, both of these disorders if not well managed, can lead to phonophobia, which is fear of sound and can further exacerabte any co-existing anxiety disorder and lead to avoidance and isolation.

‍How did you get involved with Misophonia assessment & management?

‍Through a wonderful colleague and friend, Marsh Johnson, Au.D. I attended my first Misophonia Association conference in 2018 and was hooked ever since.

‍What is your favorite thing about working with this patient population?

‍They are truly a creative group of people. I've enjoyed meeting every single misophonic patient and their families. It's truly an area in audiology that requires a lot of "out of the box" thinking.

‍Was there any additional credentialing or education you needed to acquire?

‍To my knowledge there is no credentialing needed. Misophonia is still very new in the areas of diagnosis and treatment. Currently there are no CPT or ICD-10 codes for procedures and diagnosis. If an audiologist wanted to learn more about misophonia, I would recommend reading the research available at the Duke Center for Misophonia & Emotion Regulation.  In addition, there are research papers and information at misophonia-association.org and soquiet.org. Patients, families, audiologists, psychologists, therapists may also be interested in listening to a podcast called "The Misophonia Podcast" which can be found in the Apple App store or Google Play store.

‍What are some of the common diagnostic criteria for misophonia?

‍Misophonia tends to onset between 7 and 12 years of age. It is much more prevalent in females vs. males. More information can be gathered through detailed case history and review of any other outside professional reports if available. Common trigger sounds may include: chewing, lip smacking, pen clicking, tapping, throat clearing, sniffling, foot tapping, keyboard typing, rustling of paper, and sipping liquids.

‍Can misophonia coexist with other conditions or disorders?

‍Misophonia can co-exist with sensory integration disorder, Autism Spectrum Disorder, OCD, Anxiety/Depression, ADHD, Mood disorders, and Trauma. Careful review of detailed history will determine if misophonia is stand-alone or co-exists with other diagnoses. It is important for all individuals to have a full neuropsychologic evaluation for differential diagnosis.

‍What role do audiologists play in assessment and management of misophonia?

‍A comprehensive diagnostic audiological evaluation, including extended high-frequency audiometry is important. Obtaining uncomfortable loudness levels is an important differentiator between Misophonia and Hyperacusis. Most individuals with true Misophonia have UCLs within the expected normal ranges similar to others with normal hearing ability. As for management, review of sound therapy, inclusion of the family in support of sound therapy devices in the home. Sound therapy tools can be desktop sound generators, various sound apps on iPhone/Android, and/or discreet, ear-level sound generators, especially if needed in the classroom. Exposure therapy does not work for misophonia as when individuals are exposed to their triggers, they often experience a high level of discomfort, possibly bodily/sensory pain, and/or anxiousness. Encouragement of the individual to not avoid situations where triggers could possibly occur. Avoidance leads to heightened anxiety and reinforces that negative feedback loop of considering the offending sound as a "perceived threat". It's best for them to use a blend of sound therapy with tactile tools (i.e. handball strengtheners, sitting on a yoga ball, petting a dog or cat) to help lessen their "fight or flight" response to trigger sounds.

‍What other types of professions might you collaborate with?

‍There is a vast network of possible inter-professional collaborators that you may encounter, including but not limited to: psychiatrists, psychologists, licensed therapists, occupational therapists. primary care physicians and school counselors.

‍Are there any research findings or other educational resources in the field of misophonia that audiologists should be aware of?

‍Another reference would be a book titled: "A Parent's Guide to Misophonia: Reason, Regulate & Reassure" by Jennifer Jo Brout, PsyD. She has a similar book called "An Adult's Guide to Misophonia: Reason, Regulate & Reassure". She also offers online virtual classes. More detailed information can be found on her website at https://drjenniferbrout.com/misophonia/. Dr. Brout is truly a wonderful person and psychologist, who has a wealth of knowledge in this area.

‍Are there any specific challenges or considerations that audiologists should be aware of when working with misophonia?

‍Not all patients and their family or loved ones are receptive to a management plan. There will be some who do not appreciate the need for other professionals to be involved. Some want a quick fix solution, which does not feasibly exist. That said, many people keep an open mind and use sound and tactile therapy successfully and add it to their own tool chest of things that work best for them. Most importantly, if they can get connected to the right psychologist or therapist to help work on emotional regulation skills, that support can go a long way.

‍What else should audiologists be aware of regarding management of Misophonia?

‍While sound-based therapeutic intervention can help some people, it may not be helpful to all. To date, there is no FDA approved sound therapy treatment or any peer-reviewed, evidence based treatment for misophonia. Exposure therapy does not work. So far, CBT seems to be the method of choice in working to reduce the distress from Misophonia.

‍What changes would you like to see in the healthcare community that could directly or indirectly improve quality of life for your patients?

‍This is a hard question to answer. I believe it has to start with creating more awareness and developing more understanding and compassion towards people with Misophonia. In terms of the research, we are merely scratching the surface in truly understanding misophonia within the brain. There is still more to learn in terms of management as well.

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This post is a transcript of an interview of Marni Novick, Au.D. by Melanie Rosenblatt of the California Academy of Audiology (CAA), published in March 2024.